Student Injury Report Form Guidelines
The Florida Department of Health (FDOH) provides the following Student
Injury Report Form and guidelines as an example for districts to use in tracking
the occurrence of school-related injuries. FDOH suggests completing the form
when an injury leads to any of the following:
1. The student misses 1⁄2 day or more of school.
2. The student seeks medical attention (health care provider office,
urgent care center, emergency department).
3. EMS 9-1-1 is called.
Schools are encouraged to review and use the information collected on the
injury report form to influence local policies and procedures as needed to
remedy hazards.
Instructions
• Student, parent and school information: self-explanatory.
• Check the box to indicate the location and time the incident occurred.
• Check the box to indicate if equipment was involved; describe involved
equipment. Indicate what type of surface was present where the injury
occurred.
• Using the grid, check the body area(s) where the student was injured and
indicate what type of injury occurred. Include all body areas and injuries
that apply.
• Check the appropriate box(es) for factors that may have contributed to the
student’s injury.
• Provide a detailed description of the incident. Indicate any witnesses to the
event and any staff members who were present. Attach another sheet if
more room is needed.
• Incident response: include all areas that apply.
• Provide any further comments about this incident, including any suggestions for what might prevent this type of incident in the future.
• Sign the completed form.
• Route the form to the school nurse and the principal for review/signature.
• Original form and copies should be filed according to district policy.
Florida Department of Health
Student Injury Report
Student information
Name
Date of incident
Date of birth
Grade
Male
Time of incident
Female
Parent/guardian information
Name(s)
Work phone
Address
Home phone
(
)
(
City
State
ZIP
)
Cell phone
(
)
School information
School
Phone
(
)
Location of incident circle one
Athletic field
Cafeteria
Gymnasium
Parking lot
Restroom
Bus
Classroom
Hallway
Playground
Stairway
Vocation shop/lab
In class (not P.E.)
Class change
Other explain
Time of incident circle one
Recess
Lunch
P.E. class
Before school
After school
Unknown
Field trip
Other explain
Athletic practice/session:
Athletic team competition
Intramural competition
Equipment
No equipment involved
Surface
Equipment involved describe
circle all that apply
Asphalt
Concrete
Gravel
Ice/snow
Mat(s)
Synthetic surface
Carpet
Dirt
Gymnasium floor
Lawn/grass
Sand
Tile
Wood chips/mulch
Other specify
Abrasion/scrape
Bite
Bump/swelling
Bruise
Burn/scald
Cut/laceration
Dislocation
Fracture
Pain/tenderness
Puncture
Sprain
Other
Toe
Foot
Ankle
Knee
Leg
Pelvis/hip
Genitals
Groin
Abdomen
Back
Chest/ribs
Fingernail
Finger
Hand
Wrist
Forearm
Elbow
Upper arm
Shoulder
Collarbone
Neck/throat
Chin
Jaw
Tooth/teeth
Mouth/lips
Nose
Ear
Eye
check all that apply
Head
Type of injury
Contributing factors
circle all that apply
Animal bite
Compression/pinch
Fall
Overextension/twisted
Struck by object (bat, swing, etc.)
Collision with object
Contact with hot or toxic substance
Foreign body/object
Physical Altercation
Tripped/slipped
Collision with person
Drug, alcohol or other substance involved
Hit with thrown object
Weapon specify
Struck by auto, bike, etc.
Other explain
Description of the incident
Witnesses to the incident
Staff involved
circle all that apply
Assistant staff
Cafeteria staff
Nurse
Secretary
Bus driver
Custodian
Principal
Teacher
Incident response circle all that
Other specify
apply
First Aid
Time
By whom
Called 911
Time
By whom
Parent/guardian notified
Time
By whom
Unable to contact parent/guardian
Time
By whom
Parents deemed no medical
action necessary
Returned to class
Sent/taken home
Days of school missed
Diagnosis
Days of school missed
Hospitalized
Diagnosis
Days of school missed
Restricted school activity
Explain
Taken to health care provider /
clinic/hospital/urgent care
Length of time restricted
Other explain
Describe care provided to the student
Additional comments
Signature of staff member completing form
Date/time
Nurse’s signature
Date/time
Principal’s signature
Date/time
Days of school missed